Chronic migraine and chronic tension-type headache

In 2017 the HTCC reached a final findings and decision regarding treatments for chronic migraine and chronic tension-type headache.

In 2018, the clinical committee voted to restate the language of the coverage decision to clarify eligibility requirements.

Policy context

Interventions for treatment of headaches include botulinum toxin injections, trigger point injections, transcranial magnetic stimulations, acupuncture, manipulation, manual therapy and massage. The topic is proposed to determine the safety, efficacy and value of interventions for treatment of migraines and other headache types.

Background

Headaches are among the most common reasons for patient visits in primary care and neurology settings. Headache is considered primary when a disease or other medical condition does not cause the headache. Tension-type headache is the most common primary headache and accounts for 90% of all headaches; it is characterized by a dull, non-pulsatile, diffuse, band-like (or vice-like) pain of mild to moderate intensity in the head, scalp or neck. There is no clear cause of tension-type headaches even though it has been associated with muscle contraction and stress. Migraines are the second most frequently occurring primary headaches. Migraine headache is characterized by recurrent unilateral pulsatile headaches. The two major subtypes are common migraine (without aura) and classic migraine (with aura or neurological symptoms). Chronic tension-type headache and chronic migraine will be evaluated in this report. Headaches are considered chronic if they occur 15 or more days each month for at least 3 months or more than 180 days a year. Both chronic tension-type headache and chronic migraine are associated with substantial impact on the physical, psychological and social well-being of patients as well as healthcare costs. They are a leading cause of disability and diminished quality of life. A variety of interventions may be used to treat or prevent chronic migraine and chronic tension-type headache. Interventions to be evaluated in this report include botulinum toxin injections, trigger point injections, transcranial magnetic stimulations, manipulation/manual therapy, acupuncture and massage.

OnabotulinumtoxinA (onaBoNT-A, Botox) is a type of botulinum toxin that is FDA approved for the prophylaxis of headaches in adults with chronic migraine (≥ 15 days per months with headache lasting ≥ 4 hours a day). It has been associated with reduction in the number chronic migraine headaches attacks.

Trigger point injections involve insertion of a small needle into trigger points which are muscle areas that are very irritable, show a band of tightness in the area of muscle itself, and, when pressed, produce a twitch within the affected muscle. Pain may not be confined to the affected muscle and may affect distant areas such as the head and neck, which is called referred pain. Usually local anesthetic is injected into the painful muscle and soft tissues. Trigger point injections may be done in conjunction with peripheral nerve blocks which involves injection of medication on or near nerves. Peripheral nerve blocks are not included in this review.

Transcranial magnetic stimulation involves use of a portable device that is held to the scalp and sends a series of brief magnetic pulses through the skin. FDA approval has been received for the Cerena Transcranial Magnetic Stimulator (TMS).

Manual therapies, including manipulation, involve passive movement of joints and soft tissues by hands or equipment to treat musculoskeletal and disability including headache and may be used by physiotherapists, chiropractors, osteopaths and others. Massage is often classified as a manual therapy and involves systematic and methodical manipulation of body tissues, including trigger points, usually with the hands.

Acupuncture involves the placement of thin needles (with or without manual or electrical stimulation) along specific pathways, meridians, trigger points or pain points based on the condition being treated.